1. Billie, Mary Elizabeth DNP, RN-BC, CCM
  2. Letizia, MariJo PhD, APRN/ANP-BC


Purpose/Objectives: The purpose of this project was to develop, implement, and evaluate an educational program and a serious illness (SI) protocol for a case management team of nurses and social workers to achieve the following: (1) utilize an SI protocol to identify patients with SI; (2) utilize a Serious Illness Structured Communication Guide to elicit these patients' goals and preferences for SI care; and (3) document in the electronic medical record the patients' elicited values and goals using a structured SI documentation template.


Primary Practice Setting and Sample: Seventeen nurse and 3 social work case managers in an Accountable Care Organization (ACO) in a large health system in a western suburb of Chicago participated in this project. The practice setting was the primary care clinics associated with the health system. Patients eligible for the project met the SI criteria and were part of the organization's ACO or Bundle Payment for Care Improvement program.


Methodology: Twenty members of the case management staff participated in a 4-hr face-to-face educational program, based in part on Bernacki and Block's (2014) review of best practices related to SI care and communication. Participants completed a pre- and posttest survey of knowledge; self-rated their confidence in conducting SI conversations; and evaluated the educational program. Participants then engaged in the established protocol inclusive of the following: (1) identify patients appropriate for an SI conversation; (2) initiate the SI conversation; and (3) document components of the SI in the electronic medical record.


Findings/Conclusions: Educational Program: Ninety-five percent of the RN and SW case managers reported that that the educational module objectives were met to a moderate or great extent. One hundred percent of the participants reported that the format to deliver the program was effective, the content of the program was directly relevant to their clinical practice, and they would change their practice because of learning/understanding the content in the program. Educational program pretest scores ranged from 46.2% to 84.6%, with posttest scores ranging from 69.2% to 100%. A paired-samples t test demonstrated a statistically significant increase in posttest scores. Baseline confidence scores ranged from 1 to 4, with postproject confidence scores ranging from 2 to 4. A paired-samples t test demonstrated a statistically significant increase in confidence.


Serious Illness Protocol: The case managers correctly identified 92% of patients who met the established SI identification criteria for this project. In 91.8% of cases, the case managers conducted an SI conversation in adherence to the protocol. In 76% of the cases, documentation about the SI conversation was completed in accordance with the protocol.


Implications for Case Management Practice:


* Case managers may not have had formal or informal education about engaging in conversations with patients living with an SI(s), regarding their goals of care and advanced care planning. Such education is essential, particularly if SI conversations are within the case managers' role and responsibility.


* Establishing a protocol for case managers to follow is essential, including identifying patients appropriate for an SI conversation, conducting an SI conversation, and documenting information from the SI conversation in the electronic medical record.


* Conducting SI conversations with appropriately identified patients is expected to result in the establishment of a plan of care consistent with patient preferences.